Health Assessment
Kristin Fellows, Certified Health Coach
Name
First Name
Last Name
Email
example@example.com
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
How did you hear about my program?
Preferred Method of Contact
Text
Call
Email
Awaken...Discover where you are and where you want to be!
Describe where you are in your Health now...(weight, sleep, stress, energy, etc.)
Describe where you would like to be in your health...
Please describe WHY you are interested in getting healthy. (What is your main motivation- relationships, activities, how you feel, etc.)
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)?
Medical
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
If yes, how old is your baby?
Do you have the following
Diabetes Type 1
High blood pressure
Diabetes Type 2
Gout
Do you have food allergies?
Are you taking medications for:
Diabetes
Thyroid
High Blood Pressure
Lithium
High Cholesterol
Coumadin (Warfarin)
Are you taking any medications or have other medical conditions that could influence which program we choose?
Sleep
How many hours of sleep do you get on a typical night?
What time do you typically go to bed?
What time do you typically wake up?
How is your quality of sleep?
Do you wake up feeling rested?
Hydration
How much water do you drink each day?
ounces
What other beverages do you drink daily and how much? Coffee, soda, alcohol, tea
Motion
How would you rate your energy level on a scale of 1-10?
What types of activity/movement do you do?
How many times a week do you exercise?
Are there things you can't do that you would like to be able to do?
Mind
What are your stress levels? (on a scale of 1 low-10high)
What do you do for work?
How much do you enjoy what you do?
What area of your life presents the most stress?
Eating Habits
How many times do you eat per day?
When do you eat your first meal/snack?
When do you eat your last meal/snack?
Do you snack between meals?
yes
no
If yes, what are your typical snacks?
How many times a week do you eat out and where?
Weight management
Current Weight
Current Height
Goal weight
Have you tried to lose weight before?
yes
no
What has been the most difficult about losing/maintaining weight in the past?
Surroundings
How healthy would you rate your surroundings? (1-10)
Describe your surroundings: work and home. Do you keep junk food in either or both places. Are the people you spend the most time around supportive of you? Are they healthy and active?
What do you feel your barriers to success on a healthy life path would be?
Who in your life would like to get healthy and active with you?
Submit
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